When a patient visits a doctor or, more broadly, a healthcare provider, the healthcare provider (also referred to herein as a “practice”) may create or alter its clinical and/or administrative records for that patient. Practices may use electronic health records or electronic medical records systems (referred to as “EHRs” or “EMRs,” respectively) in order to manage their patients' medical records. EHRs and EMRs may maintain key administrative and/or clinical data relevant to a practice's care of a patient over time, including demographic information, progress notes, medical problems, diagnostics, prescriptions, history of medical procedures, etc. Different EHRs and EMRs may have differing, and sometimes proprietary, software and architecture. In order to foster reliable interoperability of EHR and EMR systems among practices and other entities desiring access to healthcare records (e.g., general practitioners, specialists, inpatient care facilities, medical referral service providers, insurance providers, etc.), national and international standards for the transfer and exchange of clinical and administrative healthcare data have been developed. For example, Health Level 7 (“HL7”) standards are a set of international standards for transferring clinical and administrative data between different software applications and platforms, such as different EHRs and EMRs.
Also among the national and international standards for the transfer of healthcare-related data are a variety of standardized data architecture and document structures for organizing, storing, and conveying heath and medical records. For example, CCDs have an XML-based document format that carry a standard structure and encoding of a patient record summary. A CCD may contain a standard organization of clinical, demographic, and administrative information for a specific patient.
Various services exist to help healthcare practices perform their administrative duties. For example, electronic referrals services are services that may allow users, such as practitioners, to request automatically generated medical referrals, based on information recorded and maintained by the practitioners' EHRs and/or EMRs. Such referrals services may rely on standards for transferring medical information, such as HL7, in order to obtain the information needed from EHRs and EMRs to generate referrals. However, even with standards such as HL7 in place, referrals services must integrate with each EHR and EMR from which a referral is requested by, e.g., establishing a dedicated connection between the referrals service and each EHR and EMR, in order to communicate with, and retrieve data from, each EHR and EMR. Integration with EHRs and EMRs is often difficult due to the cost in time, finances, and human resources. If an EHR or EMR is small, then the financial resources or technical skill required to integrate the EHR or EMR with a referrals service may simply not be available. Additionally, some EHRs and EMRs will allow integration with a referrals service, but will not grant adequate access permissions to referrals services, which may result in incomplete or unsuccessful attempts by a referrals service to retrieve data needed to generate a referral.
Practices without a referrals service integrated into an EHR or EMR, or with an EHR or EMR that grants limited permissions to a referrals service, may have to resort to manually-created (e.g., manually written or typed) referrals. Additionally, referrals services may have to either pay the time or the money to integrate their systems with non-integrated EHRs and EMRs, or else forego their capability to assist practices having non-integrated EHRs or EMRs. There therefore exists a need for systems and methods that can reliably and automatically create and/or export referrals and other medical documents in a manner consistent with standardized systems, without requiring a referrals service (or other service needing medical records) to integrate its EHR or EMR into a standard system.